How should a laceration be assessed and managed 48 hours post‑injury?

Assessment and Management of Lacerations 48 Hours Post-Injury

A laceration presenting 48 hours after injury can still be safely closed with primary suturing if there are no signs of active infection, provided the wound receives thorough irrigation and proper preparation. 1

Critical Assessment at 48 Hours

When evaluating a laceration 48 hours post-injury, immediately examine for these infection indicators:

• Erythema extending beyond wound margins (>1-2 cm from wound edge) 2, 3
• Purulent drainage or exudate from the wound 2
• Increased warmth compared to surrounding tissue 3
• Systemic signs: fever >38°C, tachycardia, elevated white blood cell count (>12,000 cells/μL) 2
• Wound edema or induration 2

If any of these infection signs are present, do not perform primary closure. 1, 3 The wound requires infection treatment first, regardless of timing.

Location-Specific Timing Considerations

The 48-hour timeframe has different implications depending on anatomic location:

Facial Lacerations

• Can be closed well beyond 48 hours due to excellent facial vascularity providing superior infection resistance 1
• Even facial dog bites may receive primary closure after meticulous cleaning, despite delayed presentation 1

Hand Lacerations

• Higher risk location with increased rates of infection, septic arthritis, osteomyelitis, and tendonitis 3
• At 48 hours, carefully assess for deep structure involvement (tendon function, nerve sensation, vascular integrity) 3
• Do not close if any signs of infection, retained foreign body, or deep structure injury 3

Trunk and Extremity Lacerations

• Primary closure remains acceptable up to 24 hours as the standard recommendation 1, 4
• At 48 hours, closure is still feasible if the wound appears clean and shows no infection signs 1, 5
• Studies demonstrate no increased infection risk for wounds closed up to 18+ hours with proper technique 5, 6

Patient Risk Stratification

Identify high-risk patients who have approximately 2.7-fold increased infection risk:

• Diabetes mellitus 1, 5
• Immunosuppression 1
• Peripheral vascular disease 1

For these patients, be more conservative about closure timing and consider delayed primary closure or secondary intention healing.

Wound Preparation Protocol at 48 Hours

If proceeding with closure, meticulous preparation is essential:

1. Irrigate copiously with sterile normal saline without additives 1, 7

   • Avoid high-pressure irrigation that drives bacteria deeper 1
   • Tap water is acceptable and non-inferior to sterile saline 7, 6

2. Debride only devitalized tissue while preserving viable tissue 1

   • Remove superficial debris carefully without enlarging the wound 3
   • Be especially conservative with facial wounds 1

3. Prepare wound site with betadine or chlorhexidine antiseptic 3

Management Algorithm for 48-Hour Lacerations

If NO Infection Signs Present:

Option 1: Primary Closure

• Proceed with standard suturing technique after thorough irrigation 1, 6
• Use tissue adhesives for low-tension wounds with linear edges 7
• Dressings should remain undisturbed for minimum 48 hours after closure 4

Option 2: Delayed Primary Closure (Preferred for High-Risk Patients)

• Perform closure 2-5 days after injury once granulation tissue forms 1, 4
• This is the optimal window for delayed closure (7-10 days maximum) 3, 4

If Infection Signs ARE Present:

Do not close the wound. Management includes:

• Open wound management with dressing changes 2
• Elevation of the affected limb to accelerate healing 3, 4
• Antibiotics if systemic signs or significant cellulitis present 2
• Reassess within 24 hours for progression 3
• Consider delayed primary closure after infection resolves 1

Antibiotic Prophylaxis Decision

Do NOT prescribe prophylactic antibiotics for:

• Simple, clean lacerations on trunk or extremities (excluding hands) 1, 4

DO prescribe prophylactic antibiotics for:

• Bite wounds: amoxicillin-clavulanate 875/125 mg twice daily for 3-5 days 1
• Hand wounds (consider based on contamination level) 1
• Immunocompromised patients 1

Post-Closure Management

• Keep dressing dry and intact for 48 hours unless leakage occurs 4
• Wounds can get wet within 24-48 hours without increasing infection risk 7
• Elevate the injured area during first few days, especially if swelling present 3, 4
• Follow-up within 24 hours (phone or office visit) for wounds closed at the time limit 4
• Tetanus prophylaxis: administer 0.5 mL tetanus toxoid IM if status outdated or unknown 3, 4

Common Pitfalls to Avoid

• Do not refuse closure solely based on 48-hour elapsed time if wound appears clean and patient is low-risk 1, 5, 6
• Do not apply standard timing rules to facial wounds—their superior vascularity permits more liberal closure timing 1
• Do not close wounds with active infection—infection must be addressed first regardless of injury age 1, 3
• Do not overlook patient risk factors (diabetes, immunosuppression, peripheral vascular disease) that increase infection risk 2.7-fold 1, 5
• Do not close contaminated wounds >5 cm on lower extremities without careful consideration—these have 4-fold increased infection risk 5